C. Everett Koop: The Surgeon General Who Put Science Before Personal Ideology

Growing up, I knew some things about then-Surgeon General C. Everett Koop who died this week at the age of 96. I knew he was the guy who put the warning label on cigarettes. I knew he was the guy who said that condoms prevented AIDS. I knew he was the guy who said that kissing was okay because you would have to drink a bucket of saliva before you could possibly contract HIV. And I knew he was the guy who, like my grandfather, had a white beard, no mustache, and favored bow ties.

I didn’t know that he was also the guy who had written books on how abortion and euthanasia were going to destroy the human race. I didn’t know that he was also the guy who was left out of almost all initial discussion of AIDS by the Reagan Administration because they didn’t want to hear his rational, public health approach to the encroaching epidemic. I didn’t know to that, despite his anti-abortion stance, his final act in office was to say he could find no legitimate scientific research to support the idea that abortion causes lasting psychological harm to women. And I didn’t know just how unusual it was that in my teen years I even knew the name of the Surgeon General. Before Koop (and at times since), the nation’s top doctor was not really a public figure.

By all accounts he was a person of strong personal beliefs who nonetheless placed medical and scientific evidence, and the health of U.S. citizens over his or his administration’s ideology. While this should be the norm, in today’s political world it is shockingly rare.

Pioneering Pediatric Surgeon

Koop began his career as a pediatric surgeon. (According to accounts, he actually began his surgical career as a teenager in the basement of his parents’ town-home in Brooklyn where he operated on wounded stray animals, and he claims he never lost a “patient.”) His post-medical school career was also impressive. He became the surgeon in chief at the renowned Children’s Hospital of Philadelphia (CHOP) at a time when pediatric surgery was not yet a recognized specialty.

Over the next 35 years at CHOP he pioneered many surgeries on the youngest of patients including finding ways to correct birth defects such as hydrocephalus (the accumulation of spinal fluid in the skull), diaphragmatic hernias (a condition in which the abdominal organs push up into the chest through a hole in the child’s diaphragm), and esophageal atresia (a congenital birth defect where the esophagus is detached from the stomach). In 1956, he established the first neonatal surgical intensive care unit. During his career he also separated three sets of conjoined twins.

Outspoken Abortion Opponent

Many believe that it was this work—saving infants from near certain death—that confirmed his “pro-life” stance. In the early 1980s, Koop became involved in two legal cases in which parents refused treatment for an infant born with severe disabilities. Koop took the position that the government had to intervene, putting him at odds with liberal groups, libertarian groups, and medical groups who all argued that it was the parents’ rights, not the government’s role, to decide what was best for the child in such circumstances.

Even before that, though, Koop had become an outspoken advocate against abortion. According to the National Library of Medicine, Dr. Koop once explained:

“My concern for the unborn followed as the night, the day my concern about the newly born. How could I ever accept the destruction of the unborn after a career devoted to the repair of imperfect newborns, knowing the joy and fulfillment they brought to their families?”

Koop feared that allowing abortion because the baby was “unwanted” would pave the moral ground for euthanasia of the less desirable including the disabled and the elderly. In the late 1970s, he wrote a book The Right to Live, The Right to Die and created a multi-media presentation, titled Whatever Happened to the Human Race?, with theologian Francis Shaeffer which included five movies and an accompanying lecture. He put his medical practice on the back burner so that he and Shaeffer could travel the country delivering this presentation. In this role, he became a favorite of the burgeoning “pro-life” movement, and an Evangelical raising an issue—opposition to abortion—that had previously been seen by many as exclusive to Catholics.

A Rocky Road to Confirmation

Koop’s nomination to the role of Surgeon General in 1981 was seen as a gift to this newly powerful group of Evangelical voters who were already disappointed in Reagan’s lack of commitment to banning abortion. Not surprisingly, his appointment was met with outrage on the left. Women’s groups, medical groups, public health groups—liberals of all kinds—called on Congress to quash the nomination. Many pointed out that though a brilliant surgeon he had no public health experience and argued that the nomination was clearly based on politics and ideology.

The New York Times ran an editorial with the heading, “Dr. Unqualified,” in which it wrote:

“Since he lacks the professional qualifications for the appointment and is, in fact, older than the law routinely permits, his attractiveness to the Administration must lie elsewhere. That “elsewhere” may be his anti-abortion crusade. Two years ago he toured 20 cities with a film whose message was that abortion led inexorably to euthanasia for the elderly. And he has described amniocentesis, a procedure used to detect congenital disorders like Down’s syndrome and Tay-Sachs disease in fetuses, as a “search-and-destroy mission.”

It went on to ask Congress to: “reject the appointment, recognizing, as the Administration chooses not to, that it would be an affront both to the public health profession and the public.” The American Public Health Association agreed; its executive director said publicly that: “We’d be better off with no Surgeon General than with Koop.”

Democrats in Congress were also vocal about their opposition to Koop. The late Senator Edward Kennedy (D-MA) accused him of holding a “cruel, outdated and patronizing stereotype of women.” Representative Henry Waxman (D-CA), who remains a public health advocate in Congress to this day, called him “scary” and “intolerant.”

Koop’s confirmation process took eight months and included multiple hours of testimony—while that might seem normal nowadays (we all just watched Chuck Hagel nomination unfold), it was very unusual at the time. According to his official obituary in the New York Times he took it in stride telling his wife as they drove to DC from Philadelphia: ““If I ever have to say anything I don’t believe or feel shouldn’t be said, we’ll go home.”

A Surgeon General No One Expected

Once confirmed, Dr. Koop took on his role in a way that no one had expected. He was not political. He was not ideological. And he was not quiet (like many of his predecessors had been). He saw his position as a platform to speak to the public, and he used it.

He took on big tobacco in the fight to have specific warnings placed on all packages of cigarettes and then in an effort to make the public aware of the hazards of second-hand smoke. His efforts were successful—by the time he left office 40 states had restricted smoking in public places, 33 had prohibited it on public conveyances,17 had banned it in offices and other work sites, and the federal government had restricted smoking in 6,800 federal buildings. His end goal was of a county that was tobacco-free by 2000 alienated his friends on the Right—then-Senator Jesse Helms (R-NC), who had been one of his most ardent supporters during his nominations, unsuccessfully called for a congressional investigation of the Surgeon General.

By far, though, the most pressing and divisive topic that he dealt with during his tenure as Surgeon General was the emerging AIDS crisis. HIV and AIDS had not yet been identified when Koop took office. During his confirmation hearing, the Centers for Disease Control and Prevention (CDC) reported five cases of homosexual men in Los Angeles who were dying from Pneumocystis pneumonia, a rare form of the disease that mostly struck people with weakened immune systems. A month later, the CDC reported 26 men who had Kaposi’s sarcoma, a rare skin cancer. The National Library of Medicine notes that during his forty year career, Dr. Koop had seen only two cases of Kaposi’s sarcoma and he knew instantly that this was going to be a serious public health crisis.

Over the next few years, Acquired Immune Deficiency Syndrome (AIDS) was identified by researchers in the United States and France who then linked it to Human Immunodeficiency Virus (HIV). In those early days without a cure or a vaccine, many were arguing that the only way to stop the spread was to test everyone and quarantine all of those infected. (I was in high school at the time and I remember a mock Senate in which three separate bills were introduced to send all HIV-positive individuals to Alaska.)

Even early on, Koop took a different view. He thought that quarantine was unnecessary from an epidemiological point of view (this was not the bubonic plague) and was an infringement on individual’s rights, and he believed that mandatory testing would drive people underground. He argued for confidential testing and widespread public education to prevent the spread. And, he believed this was exactly the right role for him: “if ever there was a disease made for a Surgeon General, it was AIDS.”

But he was prevented from doing so by the White House. In fact, during Reagan’s first tirm, Koop was deliberately left out of the Administration’s discussions of the epidemic and kept off of its Executive Task Force on AIDS—journalists were instructed not to ask him about the issue.

Without Koop, the Reagan Administration famously did nothing to address the AIDS epidemic. Koop would later write that: “Our first public health priority, to stop the further transmission of the AIDS virus, became needlessly mired in the homosexual politics of the early 1980s. We lost a great deal of precious time because of this, and I suspect we lost some lives as well.” Then, in 1986, Reagan asked his Surgeon General to prepare a report about AIDS.

The Report on AIDS

Koop took great care to make sure that he report was not influenced by politics. He wrote the report himself with a small staff. He produced 17 drafts but showed only the final to the Domestic Policy Council and collected all of the copies at the end of the meeting under the guise of being afraid of press leaks. In truth he did not want an in-depth review by the policy advisers themselves. It seemed to work, there was little debate and he was not asked to make any revisions.

Jeffery Levi, the Executive Director of the Trust for America’s Health, was working at the National Gay and Lesbian Task Force at the time and was part of a small group of gay right and AIDS activities who were called in to consult with Dr. Koop’s staff during the drafting of the report. He told me:

“The meeting was quite positive, but still left us concerned that this could be a case of the staff being ahead of their boss. Given the tenor of the times we were quite worried that the report would lend support to ideological responses to the epidemic. We couldn’t have been more incorrect.”

The 36-page report explained AIDS in plain language that everyone could understand. It said how it was spread, how it was not spread, and how it could be prevented. It advocated for condom use and condom education campaigns. And it advocated for sex education for all students in the third grade and above.

Liberals were shocked. They had expected something more along the lines of a morality tale decrying homosexual sex as dangerous. Instead they got a call to action for sex education and AIDS prevention. Levi explains the reaction at the time:

“I think for those who didn’t live through the early days of the epidemic, it is hard to imagine the impact the report had on national awareness and the tone of the national discussion. It was one of those rare, transformative moments. And in the finest tradition of the office, he did not let up once the report was released. He truly behaved as the nation’s doctor, constantly reassuring and educating and calling appropriate attention—even as it made the White House uncomfortable.”

Reverend Debra Haffner, currently the President and CEO of the Religious Institute, Inc., was working at the Center for Population Options (the forerunner to Advocates for Youth) at the time. Haffner remembers being one of the liberal voices who wrote to congress demanding that they not confirm Koop and was subsequently shocked when the report, which she describes as a “clarion call at a dark time,” was released.

In 1987, Haffner and her colleagues took Dr. Koop to Hollywood where he met with television writers and producers to convince them to write stories about HIV and AIDS into their shows to educate the public in a way that the government never could. Haffner points out that his speech (of which she still has a copy) touched on all sorts of issues that were—and in many cases still are—taboo including homosexuality, race, poverty, and the need for clean needles for drug users. Dr. Koop also encouraged the writers to portray compassion to people who were living with AIDS. As Haffner reminded me:

“These were the years where nobody was talking about AIDS. Dr. Koop understood that his primary influence could be to use his office as a bully pulpit for all American by telling them the truth and not worrying about who would disagree with him.”

There is evidence to suggest that the public listened to Koop and the others who advocated a sensible approach to preventing HIV. In 1987, the condom category grew by 20 percent. Though the category continues to grow each year, this was the biggest single-year growth it has ever seen.

The following year Koop took his report directly to the American public in an eight-page, condensed version of the report, called What Every American Needs to Know About AIDS, that was mailed to all 107,000,000 households in the United States. It was the largest mailing in American history and the first time that the federal government provided explicit sex information to the public.

Joan Garrity, a colleague of mine who started doing HIV counseling and testing at the very beginning of the epidemic, recalled the import of that mailing for me:

“No one knew anything then.There was just a small subset of us in the health care field working with people who had AIDS; working with non-heterosexual people. But there was misunderstanding, misperception, and discrimination everywhere. I remember a magazine cover that said there was no way a heterosexual could get AIDS. To have the Surgeon General take the step to send this information to everyone was just amazing. “

Some saw Koop’s positions on AIDS as being antithetical to his religious beliefs because he was essentially advocating for safer sex—especially safer homosexual sex—instead of saying homosexual sex was immoral and should be avoided. Koop did not see it as a contradiction:

“My position on AIDS was dictated by scientific integrity and Christian compassion. . . . My whole career has been dedicated to prolonging lives, especially the lives of people who were weak and powerless, the disenfranchised who needed an advocate: newborns who needed surgery, handicapped children, unborn children, people with AIDS.”

Impact on Sexuality Education Haffner, who later went on to be the President of the Sexuality Information and Education Council of the U.S. (SIECUS) also points out that Koop’s report on AIDS created a great chance for sex education to expand. Sex education, which had been on the upswing in the 1970s, was facing spending cuts and opposition in the form of newly funded abstinence-only programs:

“You have to remember that at the same time, Bill Bennett was at the Department of Education pushing for abstinence-only-until-marriage programs. And Dr. Koop comes out and says that because HIV is transmitted sexually, all students need sex education starting in the third grade. That was a huge opportunity.”

Without Koop’s insistence, there was the possibility that the government’s response to AIDS, at least in terms of sex education, would have been very different. Instead, by 1989, 23 states had passed mandates for sexuality education, an additional 23 states strongly encouraged sex education, 33 had mandated AIDS education, and 17 additional states had recommended it. (Abstinence-only-until-marriage programs would have their day in the sun about a decade later but in some instances these mandates prevented such programs from having an even bigger, negative impact on what students learn.)

Koop Takes on Abortion While in Office

When Koop was nominated, his anti-choice followers had hoped he would use his office to promote their points of view but they were immediately disappointed. According to the National Library of Medicine, Dr. Koop did not see abortion as within the purview of his office:

“As Koop explained, he conceived of abortion as a moral issue that could only be resolved through moral inquiry and reform, not as a public health issue that was amenable to medical or scientific solutions.”

Reagan, however, drafted Dr. Koop into the abortion debate toward the end of his second term when he asked the Surgeon General to write a report about the psychological effects of abortion on women. Reagan, who much to the chagrin of his far-right followers had done little to restrict access abortion domestically during his presidency (though he did huge damage to women’s health internationally) believed this might be an argument that—if documented—could be used to limit abortion access. Koop was reluctant to take on the task because it was too political. In his autobiography, Dr. Koop: The Memoirs of America’s Family Doctor, he noted that he was naïve at the time and failed to understand that Reagan expected him to oppose abortion zealously.

He did not. Instead he interviewed experts and activists on both sides and found that even more so than in the debate over AIDS, anti-choicers skewed science to fit their point of view. After doing the research, he concluded that there: “was no unbiased, rigorous scientific research on the effects of abortion on women’s health that could serve as the basis for a Surgeon General’s report on the issue.”

Wendy Chavkin, an obstetrician and professor at Columbia University’s Mailman School of Public Health was running the Reproductive Health Unit at the New York City Department of Health at the time. She remembers the general feeling of dread when Reagan was elected and he in turn nominated Koop: “I was certainly nervous. It all felt like we were in the belly of the beast.” When the report came out Chavkin and others working in abortion advocacy were pleasantly surprised:

“It was just really quite amazing that someone who seemed to be very right wing and committed to that turned out to be a scientist first.”

This final act of his appointment was delivered to the White House on January 9, 1989 less than two weeks before President Reagan left office. The letter stated:

“The available scientific evidence about the psychological sequelae of abortion simply cannot support either the preconceived notions of those pro-life or those pro-choice.”

Many believe that this letter, along with his vocal actions on AIDS, is what prevented the George H.W. Bush Administration from appointing him Secretary of Health, a position which he wanted, and even keeping him on as Surgeon General. He resigned from the position in October of that year.

A Man of Science

In his tenure as Surgeon General, Dr. C. Everett Koop surprised everyone. He surprised conservatives who were sure that he would be an ally in their war against abortion. He surprised liberals who were also expecting an anti-abortion zealot. And, he surprised those in Washington and beyond who saw the Surgeon General as a position with little authority and limited influence.

As Dr. M. Joycelyn Elders, who served as Surgeon General under Bill Clinton, told RH Reality Check in a phone interview:

“There is no question that Dr. Koop raised the awareness of the office of Surgeon General for all of us. All of us who followed looked up to him and saw him as a leader among leaders. We are thankful for his vision of making health promotion and prevention important for all Americans.”

Dr. Elders went on to say that Koop’s leadership made strides not just on smoking, AIDS, and sexual health but also on mental health and obesity, an issue he was still working on when he died:

“We wouldn’t be where we are without him. He was a visionary and a risk taker and I think that what’s you have to be as Surgeon General.”

He was also one of those rare public figures who was able to put aside his own personal views and just focus on the science. Elders says that while she was in the Surgeon General’s office, Koop would call her from time to time to give his opinion:

“He really wanted to make sure that whatever we were doing was scientifically based and fair. He always believed that it didn’t matter what his own opinion was, if something was in the best interest of the country it is what we had to do.”

New Yorker writer Michael Specter interviewed Dr. Koop several times over the years and concluded that Koop was a “scientist who believed in data at least as deeply as he believed in God.” In an interview with Specter about the many ways in which the George W. Bush Administration was bending scientific fact, Koop said:

“You have to separate moral questions from the questions of science. You know, I never changed my stripes during all that time, and I still haven’t. What I did in that job was what any well-trained doctor or scientist would do: I looked at the data and then presented the facts to the American people. In science, you can’t hide from the data.”

In an era when so many people in public office try not only to hide from the data but to bend it and manipulate it to make their point or worse to hide it when it doesn’t (global warming, anyone), such a voice is all too rare. And it will be missed.

Post-script

Ironically, after his tenure as Surgeon General in which he repeatedly demonstrated scientific integrity, Koop was accused on more than one occasion of putting science aside for profit. In the late 1990s, he testified in front of Congress largely dismissing concerns that latex gloves could cause severe allergies for health care workers without ever disclosing that he had been paid over $650,000 in consulting fees by a company that manufactured such gloves. Around the same time, he asked Congress to extend the patent on the allergy drug Claritin, a move that would have meant millions to the drug’s manufacturer, without disclosing that the manufacturer had given a million dollar donation to his foundation. And many questioned whether his website, drkoop.com, actually dispensed impartial advice given that it accepted endorsement deals from a number of drug companies and had ties to chemical manufacturers as well. The website was valued at over $1 billion dollars before it went bankrupt when the dot com bubble burst.

Though he was a controversial figure throughout his life, the investors in his website banked on the fact that he was—even over a decade after leaving the post of Surgeon General—a household name. All of the tributes to him, the articles, and the numerous pictures of his recognizable white beard and bow tie that have appeared all over the internet since his death early this week show that they certainly right about that.